Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.
School of Medicine and Dentistry, Griffith University, Gold Coast, Queensland, Australia.
Emerg Med Australas. 2024 Oct;36(5):726-731. doi: 10.1111/1742-6723.14428. Epub 2024 May 2.
Pulmonary embolism (PE) frequently requires diagnosis through CT pulmonary angiogram (CTPA). Appropriate application of evidence-based clinical decision tools can reduce unnecessary CTPAs. This study assessed adherence to and the efficacy of various aspects of the Queensland Health suspected PE diagnostic pathway, including Wells score, PE rule out criteria (PERC) and age-adjusted D-dimer interpretation.
Retrospective study of CTPAs ordered from 1 January to 30 April 2023 in a tertiary and urban ED in Southeast Queensland. Data on clinical variables, D-dimer and CTPA results were collected through medical record and radiology database review. Descriptive analyses were used to determine adherence to Queensland guidelines and performance of D-dimer interpretation tools (including comparison of age-adjusted PE with a new pre-test probability [PTP]-based model using D-dimer cut-off <1000 ng/mL for Wells score ≤4 and 500 ng/mL for Wells score 4.5-6).
A total of 573 CTPAs were available for analysis with a 12.4% (95% confidence interval 10.0-15.4) diagnostic yield. Stratification by Wells score showed yields of 4.0%, 18.5% and 41% for low-, moderate- and high-risk patients, respectively. Twenty-five patients with low-PTP who received CTPA could have been excluded with the PERC rule. Age-adjusted D-dimer interpretation may have prevented 26 CTPAs with no false negatives, whereas PTP approach may have prevented 128 CTPAs with four false negatives.
Guideline adherence can be improved, and adherence to existing clinical decision tools may reduce unnecessary CTPA ordering and increase diagnostic yield. The use of the age-adjusted D-dimer had good sensitivity, whereas the new PTP approach will require further prospective research.
肺栓塞（PE）常需通过 CT 肺动脉造影（CTPA）进行诊断。适当应用基于循证的临床决策工具可减少不必要的 CTPA。本研究评估了昆士兰健康疑似 PE 诊断途径的各个方面（包括 Wells 评分、PE 排除标准[PERC]和年龄校正 D-二聚体解读）的应用情况和效果。
这是一项对昆士兰州东南部一家三级城市急诊部 2023 年 1 月 1 日至 4 月 30 日期间 CTPA 检查的回顾性研究。通过病历和放射学数据库回顾收集了临床变量、D-二聚体和 CTPA 结果的数据。采用描述性分析来确定对昆士兰指南的依从性以及 D-二聚体解读工具的性能（包括比较年龄校正的 PE 与基于新的预测试概率[PTP]的模型，该模型使用 D-二聚体截断值<1000ng/mL 用于 Wells 评分≤4 和 500ng/mL 用于 Wells 评分 4.5-6）。
共分析了 573 份 CTPA，其诊断率为 12.4%（95%置信区间 10.0-15.4）。按 Wells 评分分层，低危、中危和高危患者的诊断率分别为 4.0%、18.5%和 41%。25 例低 PTP 患者如果使用 PERC 规则可避免进行 CTPA。年龄校正的 D-二聚体解读可能避免了 26 例无假阴性的 CTPA，而 PTP 方法可能避免了 128 例有 4 例假阴性的 CTPA。
可提高指南依从性，并且对现有临床决策工具的依从性可能减少不必要的 CTPA 检查，提高诊断率。年龄校正的 D-二聚体具有良好的敏感性，而新的 PTP 方法需要进一步的前瞻性研究。
